ATI RN
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ATI N 144 Exam 1 Fundamental Concepts for Nursing Practice Questions
Extract:
Question
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1 of 5
A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?
Correct Answer: A
Rationale: Stabilizing the object is the priority nursing action for a penetrating eye injury. Stabilizing the object prevents further damage to the eye structures and reduces the risk of infection and bleeding. The nurse should use a protective shield or cup to cover the eye and secure the object in place and avoid applying any pressure or movement to the eye. Applying anesthetic drops removing the object or using ointment could worsen the injury and are not initial priorities.
Question 2 of 5
The RN receives a call from the lab that a client's potassium chloride (KCl) level is 6.6 (normal range is 3.5 to 5 mEq/L). What should the nurse do first?
Correct Answer: A
Rationale: Stopping the KCl infusion is the first and most urgent action that the nurse should take. A high level of potassium in the blood or hyperkalemia can cause life-threatening cardiac arrhythmias and muscle weakness. The nurse should stop the source of excess potassium which is the KCl infusion and monitor the client’s vital signs electrocardiogram and symptoms. Administering more KCl or encouraging fluids without stopping the infusion would worsen the condition. Calling the pharmacy is secondary to stopping the infusion.
Question 3 of 5
A client is 24 hours post-op after having a colon resection. His abdominal incision is dry and intact,but the nurse notes that bowel sounds have not returned. What condition is this client likely experiencing?
Correct Answer: A
Rationale: Paralytic ileus is a condition in which the intestinal motility is decreased or absent resulting in the inability to pass gas or stool. It is a common complication of abdominal surgery as the manipulation of the bowel can cause inflammation and nerve damage. Clostridium difficile colitis involves diarrhea not absent bowel sounds. Constipation and fecal impaction are related to opioid use or chronic issues not immediate post-op complications.
Question 4 of 5
A nurse on a medical-surgical unit knows that for clients with a BMI greater than or equal to 30,it is important to:
Correct Answer: B
Rationale: Using an appropriately sized blood pressure cuff is critical for clients with a BMI ≥ 30 to ensure accurate readings. Supine positioning can impair breathing in obese clients. Obesity does not indicate malnutrition/underweight. Frail bones are associated with osteoporosis not obesity though mobility issues may warrant fall precautions.
Question 5 of 5
A client continues to report post-surgical incision pain at a level of 9 out of 10 after pain medication is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?
Correct Answer: B
Rationale: Exploring other options for pain relief is the first action that the critically thinking nurse should take. The nurse should assess the patient’s pain level , location , quality, and contributing factors , and use a multimodal approach to pain management that includes pharmacological and non-pharmacological interventions,such as ice, heat,distraction,relaxation,or massage. Delaying notification discussing the procedure,or stating no other orders exist do not address the immediate pain.